Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
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Release Notes:
Data Element
Version 2020B

Name:Education Addresses Follow-up After Discharge
Collected For: STK-8
Definition:Documentation that the patient/caregiver received educational materials that address the need for continuing medical care after discharge. Patient education programs for specific chronic conditions have increased healthful behaviors, improved health status, and/or decreased health care costs of their participants.
Question:Did the WRITTEN instructions or other documentation of educational material given to the patient/caregiver address follow-up with a physician/APN/PA after discharge?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)     WRITTEN instructions/educational material given to patient/caregiver address follow-up with a physician/APN/PA after discharge.

N (No)     WRITTEN instructions/educational material do not address follow-up with a physician/APN/PA or unable to determine from medical record documentation.
Notes for Abstraction:
  • Educational material must address follow-up after discharge.
    Example:
    “It is important for you to keep all follow-up appointments with your physician and reschedule appointments that you cannot make as soon as possible.”
  • Educational material which addresses follow-up after discharge for transient ischemic attack (TIA) is acceptable.
  • If the medical record contains documentation of education that does not include stroke and follow-up after discharge, select “No.”
    Examples:
    • “Stroke binder given to patient’s family.”
    • “Aneurysm education completed.”
  • Documentation must reflect that follow-up after discharge will be with a physician/APN/PA in order to select “Yes” for this data element. The date, time, and name of the provider may be mentioned in the written material but all three are not required to select “Yes”.
  • In the absence of explicit documentation that follow-up involves contact with a physician/APN/PA, the abstractor may infer contact with a physician/APN/PA, unless documentation suggests otherwise (e.g., BP check, laboratory work only).
  • If documentation reflects that educational material regarding follow-up after discharge was given to the patient/caregiver, select “Yes”, even if a copy of the material is not present in the medical record.
  • Documentation must clearly convey that the patient/caregiver was given a copy of the material to take home. When the material is present in the medical record and there is no documentation which clearly suggests that a copy was given, the inference should be made that it was given IF the patient's name or the medical record number appears on the material AND hospital staff or the patient/caregiver has signed the material. An electronic staff signature is acceptable. This applies to educational materials in the form of printed, electronic, or digital patient-oriented materials. Providing a link to electronic materials is not sufficient.
  • Use only documentation provided in the medical record itself. Do not review and use outside materials in abstraction. Do not make assumptions about what content may be covered in material documented as given to the patient/caregiver.
  • Written instructions given anytime during the hospital stay are acceptable.
  • If the medical record contains documentation that instructions were given or sent to the patient/caregiver after discharge, select “No.”
  • If the patient refused written instructions/material which addressed follow-up, select “Yes.”
  • If documentation indicates that written instructions/material on follow-up after discharge were not given because the patient is cognitively impaired (e.g., comatose, obtunded, confused, short-term memory loss) and has no caregiver available, select “Yes.”
  • The caregiver is defined as the patient’s family or any other person (e.g.,home health, VNA provider, prison official or other law enforcement personnel) who will be responsible for care of the patient after discharge.
Suggested Data Sources:
  • Nursing notes
  • Progress notes
  • Discharge summary
  • After Visit Summary (AVS)
  • Discharge instruction sheet
  • Education Record
  • Home health referral form
  • Nursing discharge notes
  • Teaching sheet

Excluded Data Sources:
  • Any documentation dated/timed after discharge, except discharge summary
  • Core measure forms
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • None

  • Follow-up prescribed on PRN or as needed basis
  • Follow-up noted only “as directed” or “as instructed”
  • Follow-up noted only as Not Applicable (N/A), None, or left blank
  • Follow-up only in the form of a direction to the patient to bring a copy of a form to their next appointment
  • Pre-printed follow-up appointment instruction with all fields left blank (e.g., “Please return for follow up appointment with Dr. [blank line] on [blank line],” "Make an appointment with your physician in [blank line] for follow up"), unless next to checked checkbox
  • Unchecked checkbox next to instruction (e.g., blank checkbox on discharge instruction sheet next to “Call Dr.’s office for appointment within two weeks”)

Education Addresses Follow-up After Discharge
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Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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